Management of biliary complications following living donor liver transplantation—a single center experience

Living Donor Liver Transplantation Using Selected Grafts With 2 Bile Ducts Compared With 1 Bile Duct Does Not Impact Patient Outcome

The outcome after living donor liver transplantation (LDLT) using grafts with multiple bile ducts (BDs) remains unclear. We analyzed 510 patients who received an adult-to-adult right lobe LDLT between 2000 and 2015 and compared outcome parameters of those receiving grafts with 2 BDs (n = 169) with patients receiving grafts with 1 BD (n = 320). Additionally, patients receiving a graft with 3 BDs (n = 21) were analyzed. Demographic variables and disease severity were similar between the groups. Roux-en-Y reconstruction was significantly more common in the 2 BD group (77% versus 38%; P < 0.001) compared with the 1 BD group. No difference was found in biliary complication rates within 1 year after LDLT (1 BD versus 2 BD groups, 18% versus 21%, respectively; P = 0.46). In the 2 BD group, 82/169 (48.5%) patients were reconstructed with 2 anastomoses. The number of anastomoses did not negatively impact biliary complication rates. Recipients' major complication rate (Clavien ≥ 3b) was similar between both groups (1 BD versus 2 BD groups, 21% versus 24%, respectively; P = 0.36). Furthermore, no difference could be found between the 1 BD, the 2 BD, and the 3 BD groups in the frequency of developing biliary complications within 1 year (18%, 21%, 14%, respectively; P = 0.64), BD strictures (15%, 15%, 5%, respectively; P = 0.42), or BD leaks (10%, 11%, 10%, respectively; P = 0.98). In addition, the 1-year (90% versus 91%), 5-year (82% versus 77%), and 10-year (70% versus 66%) graft survival rates as well as the 1-year (92% versus 93%), 5-year (84% versus 80%), and 10-year (75% versus 76%) patient survival rates were comparable between the 1 BD and the 2 BD groups (P = 0.41 and P = 0.54, respectively). In conclusion, this study demonstrates that selected living donor grafts with 2 BDs can be used safely without negatively impacting biliary complication rates and graft or patient survival rates.

Status of Adult Living Donor Liver Transplantation in the United States: Results from the Adult-To-Adult Living Donor Liver Transplantation Cohort Study

This article reviews the Adult-to-Adult Living Donor Liver Transplant Cohort Study (A2ALL). The findings show that the number of adult-to-adult living donor liver transplants is consistently increasing. Living donor liver transplantation has an important benefit for patients with acute liver failure, does not compromise donor safety, and has lower rates of acute cellular rejection in biologically related donor and recipient. The conclusions from the A2ALL consortium have been critical in transplant advancement, supporting increased use to help decrease waitlist death and improve long-term survival of transplant recipients.

Biliary complications after living donor liver transplantation: A retrospective analysis of the Kyoto experience 1999-2004

BACKGROUND AND AIM

In living donor liver transplantation (LDLT), biliary complications continue to be the most frequent cause of morbidity and may contribute to mortality of recipients although there are advances in surgical techniques. This study will evaluate retrospectively the short-term and long-term management of biliary complications.

METHODS

During the period from May 1999, to May 2004, 505 patients underwent 518 LDLT in the Department of Liver Transplantation and Immunology, Kyoto University Hospital, Japan. The data was collected and analyzed retrospectively.

RESULTS

The recipients were 261 males (50.4%) and 257 females (49.6%). Biliary complications were reported in 202/518 patients (39.0%), included; biliary leakage in 79/518 (15.4%) patients, leakage followed by biloma in 13/518 (2.5%) patients, leakage followed by stricture in 9/518 (1.8%) patients, and biliary strictures in 101/518 (19.3%) patients. Proper management of the biliary complications resulted in a significant (p value 0.002) success rate of 96.5% compared to the failure rate which was 3.5%.

CONCLUSION

Careful preoperative evaluation and the proper intraoperative techniques in biliary reconstruction decrease biliary complications. Early diagnosis and proper management of biliary complications can decrease their effect on both the patient and the graft survival over the long period of follow up.

Roux-en-Y hepatico-jejunostomy for a left segmental graft: Do not twist the loop, stick it!

Biliary complications remain a major challenge for long-term success after LT, as it is, as a rule, the most common technical - early and late - complication that occurs, and because these complications contribute to a significant number of late graft losses and retransplantations. In the pediatric age group, both biliary atresia, as the patient's condition, and the use of a left liver graft, obtained by a liver division technique, make it necessary for the use of a Roux-en-Y jejunal loop for the biliary reconstruction in the majority of cases. A slight modification of the technique is presented, consisting of a straight positioning along the cut surface (rather than the conventional position that results in a harpoon shape). A favorable outcome in terms of a technical complication and graft survival was observed. This way of doing this is an interesting variation and adds to the surgical armamentarium.

Biliary complications after liver transplantation

Biliary complications (BCs) remain one of the most outstanding factors influencing long-term results after orthotopic liver transplantation. The authors carried out a systematic overview of 1720 papers since 2008, and focused on 45 relevant ones. Among 14,411 transplanted patients the incidence of BCs was 23%. Biliary leakage occurred in 8.5%, biliary stricture in 14.7%, mortality rate was 1-3%.

RISK FACTORS

preoperative sodium level; p = 0.037, model of end-stage liver disease score >25; p = 0.048, primary sclerosing cholangitis; p = 0.001, malignancy; p = 0.026, donor age >60, macrovesicular graft steatosis; p = 0.001, duct-to-duct anastomosis; p = 0.004, long anhepatic phase; p = 0.04, cold ischemic time >12 h; p = 0.043, use of T-tube; p = 0.032, insufficient flush of bile ducts; p = 0.001, acute rejection; p = 0.003, cytomegalovirus infection; p = 0.004 and hepatic artery thrombosis; p = 0.001. The management was surgical in case of biliary leakage, and interventional radiology or endoscopic retrograde cholangiopancreatography in case of biliary stricture. Mapping of miRNA profile is a new field of research. Nemes-Doros score is a useful tool in the estimation of hepatic artery thrombosis. Management of BCs requires a multidisciplinary expert team.

Biliary reconstruction and complications in adult living donor liver transplantation: systematic review and meta-analysis

OBJECTIVE

The purpose of this meta-analysis was to compare outcomes of different techniques used for biliary reconstruction in adult donor liver transplantation.

METHODS

We searched the literature via Pubmed, Embase, Ovid, the Cochrane Hepato-Biliary Group Controlled Trials Regsistry, the Cochrane Central Registry of Controlled Trials, the Cochrane Library database, and Web of Science. Then with the data extracted from the literature, the effects that biliary reconstruction techniques in living-donor liver transplantation (LDLT) had on the occurrence of biliary complications were compared. With the use of random-effects and fixed-effect models, the results were obtained and expressed as odds ratio.

RESULTS

We found 16 eligible studies from various medical centers around the world. Duct-to-duct (DD) reconstruction was performed in the majority of patients (922/1,564). Multiple biliary ducts were encountered in 16.7%-60.4%, and ductoplasty was performed in 7.9%-74% of the patients. Both graft and posterior layer of bile duct anastomosis in DD reconstruction were studied, and no statistically differences in incidence of biliary complications were found between the Roux-en-Y hepaticojejunostomy (RYHJ) and DD groups. Nonsurgical management of biliary complications was the first choice of treatment.

CONCLUSIONS

Our study found that there is no clear evidence in favor of using DD or RYHJ during adult LDLT.

Development, management, and resolution of biliary complications after living and deceased donor liver transplantation: a report from the adult-to-adult living donor liver transplantation cohort study consortium

Adult recipients of living donor liver transplantation (LDLT) have a higher incidence of biliary complications than recipients of deceased donor liver transplantation (DDLT). Our objective was to define the intensity of the interventions and the time to resolution after the diagnosis of biliary complications after liver transplantation. We analyzed the management and resolution of posttransplant biliary complications and investigated the comparative effectiveness of interventions in LDLT and DDLT recipients. For the analysis of biliary complications (leaks or strictures), we used a retrospective cohort of patients who underwent liver transplantation at 8 centers between 1998 and 2006 (median follow-up from onset=4.7 years). The numbers, procedure types, and times to resolution were compared for LDLT and DDLT recipients. Posttransplant biliary complications occurred in 47 of the 189 DDLT recipients (25%) and in 141 of the 356 LDLT recipients (40%). Biliary leaks constituted 38% of the post-DDLT biliary complications (n=18) and 65% of the post-LDLT biliary complications (n=91). The median times to first biliary complications were similar for DDLT and LDLT (11 versus 14 days for leaks, P=0.63; 69 versus 107 days for strictures, P=0.34). Overall, 1225 diagnostic and therapeutic procedures, including reoperation and retransplantation, were performed (6.5±5.4 per recipient; 5.5±3.6 for DDLT versus 6.8±5.8 for LDLT, P=0.52). The median number of months to the resolution of a biliary complication (i.e., a tube-, stent-, and drain-free status) did not significantly differ between the DDLT and LDLT groups for leaks (2.3 versus 1.3 months, P=0.29) or strictures (4.9 versus 2.3 months, P=0.61). Although the incidence of biliary complications is higher after LDLT versus DDLT, the treatment requirements and the time to resolution after the development of a biliary complication are similar for LDLT and DDLT recipients.

Transhilar passage in right graft live donor liver transplantation: intrahilar anatomy and its impact on operative strategy

The passage through the hilar plate during right graft live donor liver transplantation (LDLT) can have dangerous consequences for both donors and recipients. The purpose of our study was to delineate hilar transection and biliary reconstruction strategies in right graft LDLT, with special consideration of central and peripheral hilar anatomical variants. A total of 71 consecutive donors underwent preoperative three-dimensional (3D) CT reconstructions and virtual 3D hepatectomies. A three-modal hilar passage strategy was applied, and its impact on operative strategy analyzed. In 68.4% of cases, type I and II anatomical configurations allowed for an en block hilar transection with simple anastomotic reconstructions. In 23.6% of cases, donors had "difficult" type II and types III/IV hilar bile duct anatomy that required stepwise hilar transections and complex graft biliary reconstructions. Morbidity rates for our early (A) and recent (B) experience periods were 67% and 39%, respectively. (1) Our two-level classification and 3D imaging technique allowed for donor-individualized transhilar passage. (2) A stepwise transhilar passage was favored in types III and IV inside the right-sided hilar corridor. (3) Reconstruction techniques showed no ameliorating effect on early/late biliary morbidity rates.

Surgical revision of biliary strictures following adult live donor liver transplantation: patient selection, morbidity, and outcomes

Biliary strictures after live donor liver transplantation (LDLT) are frequent and difficult to manage. The outcomes of surgical correction of biliary anastomotic complications remain unclear. Clinical outcomes of patients requiring surgical revision of their biliary anastomosis following LDLT were analyzed. Of 296 consecutive right lobe LDLTs, approximately 21% of patients developed biliary strictures. Of these patients, twelve required surgical revision of a biliary anastomotic stricture. For patients who had operative repair, the average time from transplantation to stricture diagnosis was 7.6 months. Mean time to surgical correction was 8.2 months from the time of stricture diagnosis. Eight of 12 (67%) patients no longer require any intervention with a mean follow-up of 43.7 months. Two of 12 patients require intermittent medical treatment for presumed cholangitis, but have not required biliary interventions. Two patients have required chronic PTC catheter drainage. The 30-day postoperative morbidity was 58%, with four serious (Grade 3) complications occurring in three patients. Early stricture repair (<6 months from diagnosis of stricture) and younger donor grafts were associated with better surgical outcomes. Timely surgical correction of biliary strictures is successful and durable in appropriately selected patients. However, operative repair is associated with significant postoperative morbidity.

Biliary complications after living donor liver transplantation

Biliary complications occur more frequently after living donor liver transplantation (LDLT) versus deceased donor liver transplantation, and they remain the most common and intractable problems after LDLT. The anatomical limitations of multiple tiny bile ducts and the differential blood supplies of the graft ducts may be significant factors in the pathophysiological mechanisms of biliary complications in patients undergoing LDLT. A clear understanding of the biliary blood supply, the Glissonian sheath, and the hilar plate has contributed to new techniques for preparing bile ducts for anastomosis, and these techniques have resulted in a dramatic drop in the incidence of biliary complications. Most biliary complications after LDLT can be successfully treated with nonsurgical approaches, although the management of multiple biliary anastomoses and nonanastomotic strictures continues to be a challenge.

Plastic biliary stents for benign biliary diseases

Biliary plastic stenting plays a key role in the endoscopic management of benign biliary diseases. Complications following surgery of the biliary tract and liver transplantation are amenable to endoscopic treatment by plastic stenting. Insertion of an increasing number of plastic stents is currently the method of choice to treat postoperative biliary strictures. Benign biliary strictures secondary to chronic pancreatitis or primary sclerosing cholangitis may benefit from plastic stenting in select cases. There is a role for plastic stent placement in nonoperative candidates with acute cholecystitis and in patients with irretrievable bile duct stones.

Biliary complications in 106 consecutive duct-to-duct biliary reconstruction in right-lobe living donor liver transplantation performed in 1 year in a single center: a new surgical technique

OBJECTIVE

Biliary complications remain a major source of morbidity after living donor liver transplantation (LDLT). Of 109 consecutive right lobe (RL)-LDLTs performed in 1 year in our institution, we present the biliary complications among 106 patients who underwent a new duct-to-duct anastomosis technique known as University of Inonu.

METHODS

Of 153 liver transplantations performed in 1 year from January to December of 2008, 128 were LDLTs including 109 RL-LDLTs. The others were left or left lateral grafts. All RL-LDLT patients were adults, all of whom except three included a duct-to-duct anastomosis.

RESULTS

All, but three, biliary reconstructions were completed with a surgical technique, so called UI, in which 6-0 prolene sutures were used. Nine bile leaks were seen in 106 recipients (8.49%) performed in a duct-to-duct fashion in a time period of 1 to 4 weeks. Seventeen patients (16.03%) posed bile duct stricture (BDS). Five patients had both. Although endoscopic stent placement and percutaneous balloon dilatation, 4 patients continued to suffer from BDS on whom a permanent access hepatico-jejunostomy (PAHJ) procedures were performed.

CONCLUSION

We recommend a duct-to-duct biliary reconstruction because of its de facto advantages over other types of anastomosis provided the native duct is not diseased. After almost 2 years, the bile tract complication rate was 22.64%.

Prospective evaluation of biliary reconstruction with duct-to-duct continuous suture in adult live donor liver transplantation

Purpose

Biliary reconstruction remains the Achilles’ heel of adult live donor liver transplantation (LDLT). The study aims to investigate the feasibility of duct-to-duct hepaticocholedochostomy in LDLT.

Methods

Perioperative data from 30 consecutive LDLT aiming at duct-to-duct reconstruction of the biliary tract using a continuous suture technique were prospectively collected. Nineteen recipients (63.3%) had one graft bile duct. Eleven recipients (36.7%) had two or three graft bile ducts. The median follow-up was 50 months.

Results

The overall biliary complication rate was 23.3%. Two recipients developed biliary stricture (6.7%), and two recipients (6.7%) presented with biliary leakage in early posttransplant phase (<90 days). One recipient suffered from bilioma (3.3%), and two recipients (6.7%) presented with biliary stricture in later posttransplant phase (>90 days). No correlation was found between the number of graft bile ducts and the incidence of biliary complications. No biliary complication-associated necessity for re-transplantation or mortality was observed. On multivariate analysis, no single risk factor associated with biliary complication could be identified. All biliary complications were successfully treated with Roux-en-hepaticojejunostomy and/or with endoscopic interventions.

Conclusion

Duct-to-duct hepaticocholedochostomy with continues suture represents a safe and feasible procedure for biliary reconstruction in LDLT. Recipients may benefit from aggressive management of biliary complications with Roux-en-hepaticojejunostomy as compared with repeated endoscopic interventions in early posttransplant phase.